Do sleep abnormalities and misaligned sleep/circadian rhythm patterns represent early clinical characteristics for developing psychosis in high risk populations?

Causal associations between sleep traits and brain structure: a bidirectional Mendelian randomization study

BACKGROUND

Emerging evidence suggests bidirectional causal relationships between sleep disturbance and psychiatric disorders, but the underlying mechanisms remain unclear. Understanding the bidirectional causality between sleep traits and brain imaging-derived phenotypes (IDPs) will help elucidate the mechanisms. Although previous studies have identified a range of structural differences in the brains of individuals with sleep disorders, it is still uncertain whether grey matter (GM) volume alterations precede or rather follow from the development of sleep disorders.

RESULTS

After Bonferroni correction, the forward MR analysis showed that insomnia complaint remained positively associated with the surface area (SA) of medial orbitofrontal cortex (β, 0.26; 95% CI, 0.15-0.37; P = 5.27 × 10-6). In the inverse MR analysis, higher global cortical SA predisposed individuals less prone to suffering insomnia complaint (OR, 0.89; 95%CI, 0.85-0.94; P = 1.51 × 10-5) and short sleep (≤ 6 h; OR, 0.98; 95%CI, 0.97-0.99; P = 1.51 × 10-5), while higher SA in posterior cingulate cortex resulted in a vulnerability to shorter sleep durations (β, - 0.09; 95%CI, - 0.13 to - 0.05; P = 1.21 × 10-5).

CONCLUSIONS

Sleep habits not only result from but also contribute to alterations in brain structure, which may shed light on the possible mechanisms linking sleep behaviours with neuropsychiatric disorders, and offer new strategies for prevention and intervention in psychiatric disorders and sleep disturbance.

Linguistic and non-linguistic markers of disorganization in psychotic illness

BACKGROUND

Disorganization, presenting as impairment in thought, language and goal-directed behavior, is a core multidimensional syndrome of psychotic disorders. This study examined whether scalable computational measures of spoken language, and smartphone usage pattern, could serve as digital biomarkers of clinical disorganization symptoms.

METHODS

We examined in a longitudinal cohort of adults with a psychotic disorder, the associations between clinical measures of disorganization and computational measures of 1) spoken language derived from monthly, semi-structured, recorded clinical interviews; and 2) smartphone usage pattern derived via passive sensing technologies over the month prior to the interview. The language features included speech quantity, rate, fluency, and semantic regularity. The smartphone features included data missingness and phone usage during sleep time. The clinical measures consisted of the Positive and Negative Symptom Scale (PANSS) conceptual disorganization, difficulty in abstract thinking, and poor attention, items. Mixed linear regression analyses were used to estimate both fixed and random effects.

RESULTS

Greater severity of clinical symptoms of conceptual disorganization was associated with greater verbosity and more disfluent speech. Greater severity of conceptual disorganization was also associated with greater missingness of smartphone data, and greater smartphone usage during sleep time. While the observed associations were significant across the group, there was also significant variation between individuals.

CONCLUSIONS

The findings suggest that digital measures of speech disfluency may serve as scalable markers of conceptual disorganization. The findings warrant further investigation into the use of recorded interviews and passive sensing technologies to assist in the characterization and tracking of psychotic illness.

Sleep Disturbances in At-Risk Mental States and First Episode of Psychosis: A Narrative Review on Interventions

Sleep disturbances are a common yet often overlooked symptom of psychosis that can drastically affect the quality of life and well-being of those living with the condition. Sleep disorders are common in people diagnosed with schizophrenia and have significant negative effects on the clinical course of the illness and the functional outcomes and quality of life of patients. There is a limited number of studies addressing this question in first-episode psychosis (FEP). In this narrative review, we aimed to provide an overview of sleep disorders in populations with FEP and at-risk mental states (ARMS). The review was focused on the various treatments currently used for sleep disorders, including both non-pharmacological and pharmacological treatments. A total of 48 studies were included. We found that sleep disturbances are associated with attenuated psychotic symptoms and other psychopathological symptoms in ARMSs. The association of sleep disturbances with the transition to psychosis has been poorly investigated. Sleep disturbances have an impact on the quality of life and the psychopathological symptoms of people suffering from FEP. The non-pharmacological treatments include cognitive behavioral therapy for insomnia, bright light therapy, cognitive restructuring techniques, sleep restriction therapy, basic sleep hygiene education, and the provision of portable sleep trackers. Other treatments include antipsychotics in acute phases and melatonin. The early intervention in sleep disturbances may improve overall prognosis in emerging psychosis populations.

The examination of sleep hygiene, quality of life, and schizotypy in young adults

The co-occurrence of sleep disruption and schizophrenia-spectrum symptomology is common, with current research supporting the use of interventions, such as cognitive behavioral therapy for insomnia (CBTi), which include sleep hygiene education. Sleep hygiene refers to patterns of pre-sleep behaviors that can promote or impair sleep. These behaviors are easily identified and modifiable, potentially holding promise as targets of research and clinical practice. However, there is little research examining sleep hygiene in those at-risk for schizophrenia, measured through clusters of sub-clinical symptoms known as schizotypy. Given the likelihood poor sleep exacerbates negative emotions, thus serving as an etiologically relevant stressor, the study of sleep hygiene in at-risk populations appears warranted. Additionally, quality of life (QOL) has previously been shown to be negatively associated with sleep hygiene and schizophrenia-spectrum risk. As such, QOL domains were included to quantify the extent pre-sleep habits and dimensional schizotypy impact individuals' wellbeing. Data was collected from a non-clinical sample of 385 young adults (M = 20.83, SD = 3.61). As anticipated, higher schizotypy was correlated with poorer sleep hygiene and reduced QOL, although only negative schizotypy predicted QOL in the final regression model controlling for sex differences. Sex differences were present for all variables of interest except disorganized schizotypy. Post-hoc item-level analyses suggested that higher levels of schizotypy were correlated with emotional rumination prior to sleep, while increased negative schizotypy was associated with reduced QOL. Future research should further evaluate sleep hygiene as a potentially relevant risk variable in the development of schizophrenia-spectrum symptomology and associated decline in QOL.

Neurobiological and behavioral mechanisms of circadian rhythm disruption in bipolar disorder: A critical multi-disciplinary literature review and agenda for future research from the ISBD task force on chronobiology

AIM

Symptoms of bipolar disorder (BD) include changes in mood, activity, energy, sleep, and appetite. Since many of these processes are regulated by circadian function, circadian rhythm disturbance has been examined as a biological feature underlying BD. The International Society for Bipolar Disorders Chronobiology Task Force (CTF) was commissioned to review evidence for neurobiological and behavioral mechanisms pertinent to BD.

METHOD

Drawing upon expertise in animal models, biomarkers, physiology, and behavior, CTF analyzed the relevant cross-disciplinary literature to precisely frame the discussion around circadian rhythm disruption in BD, highlight key findings, and for the first time integrate findings across levels of analysis to develop an internally consistent, coherent theoretical framework.

RESULTS

Evidence from multiple sources implicates the circadian system in mood regulation, with corresponding associations with BD diagnoses and mood-related traits reported across genetic, cellular, physiological, and behavioral domains. However, circadian disruption does not appear to be specific to BD and is present across a variety of high-risk, prodromal, and syndromic psychiatric disorders. Substantial variability and ambiguity among the definitions, concepts and assumptions underlying the research have limited replication and the emergence of consensus findings.

CONCLUSIONS

Future research in circadian rhythms and its role in BD is warranted. Well-powered studies that carefully define associations between BD-related and chronobiologically-related constructs, and integrate across levels of analysis will be most illuminating.

The relationship between stress responding in family context and stress sensitivity with sleep dysfunction in individuals at clinical high-risk for psychosis

Stress and sleep have been implicated in the etiology of psychosis, and literature suggests they are closely related. Two distinct domains of stress associated with sleep dysfunction in the general population are responsivity to environmental stressors and stress sensitivity. However, to date, no research has examined relationships between these stress domains and sleep dysfunction in individuals at clinical high-risk (CHR) for psychosis. A total of 57 CHR (mean age = 18.89, SD = 1.82) and 61 healthy control (HC; mean age = 18.34, SD = 2.41) adolescents and young adults completed a measure of emerging stress intolerance. A subset of participants (CHR = 50, HC = 49) completed a measure indexing responsivity to family stressors - an integral context for this developmental stage overlapping with the psychosis-risk period. Sleep efficiency, continuity, and duration were objectively assessed by actigraphy (CHR = 38, HC = 36). Partial correlations with age and sex as covariates were conducted in both groups separately to examine relationships between stress and sleep. Results indicated that automatic maladaptive responsivity to family stressors was associated with disrupted sleep in the CHR but not HC group. Specifically, greater involuntary engagement was associated with poorer sleep efficiency (r = -.42) but not sleep continuity (r = 0.31) and duration (r = .-19). Interestingly, both adaptative and maladaptive voluntary responses to stressors (engagement and disengagement coping) were not associated with sleep. Finally, impaired stress tolerance was associated with sleep efficiency (r = -0.47), continuity (r = 0.37), and duration (r = -0.43). Taken together, findings provided important groundwork for understanding the role of the relationship between involuntary maladaptive responsivity to family stressors and stress sensitivity with sleep in psychosis etiology.

The nature, consequences, mechanisms, and management of sleep disturbances in individuals at-risk for psychosis

There is strong evidence that sleep disturbances are commonly experienced by people with psychosis. Evidence has also shown that sleep disturbances are present since the very early stages of the disease, even during the pre-diagnostic phase. More recently, research involving young individuals at ultra-high risk (UHR) for psychosis documented frequent occurrence of sleep disturbances in this group. The very early onset of sleep disturbances in the course of psychosis has drawn attention to the possible links between sleep parameters and the risk of psychosis. To date, the nature of sleep disturbances characterizing the UHR stage remains unclear, with available studies having yielded mixed findings. In this regard, we performed this review to update the body of literature on the nature of sleep disturbances, their underlying mechanisms, their clinical and functional consequences, the prevention and intervention strategies in the at-risk for psychosis population. Our findings provided further support to the presence of disturbed sleep in UHR individuals as evidenced by subjective and objective sleep measures such as polysomnography, sleep electroencephalograms, and actigraphy. Reviewing the possible mechanisms underlying the relationship between sleep and psychosis emphasized its complex and multifactorial nature which is yet to be determined and understood. Further research is warranted to determine which facets of sleep disturbances are most detrimental to this specific population, and to what extent they can be causal factors or markers of psychosis.

The Impact of Sleep on Neurocognition and Functioning in Schizophrenia—Is It Time to Wake-Up?

People with schizophrenia (SZ) display substantial neurocognitive deficits that have been implicated as major contributors to poor daily functioning and disability. Previous reports have identified a number of predictors of poor neurocognition in SZ including demographics, symptoms, and treatment adherence, as well as body mass index, aerobic fitness, and exercise activity. However, the putative impact of sleep has received relatively limited consideration, despite sleep disturbances, which are pervasive in this population, resulting in symptoms that are strikingly similar to the neurocognitive deficits commonly observed in SZ. Here we argue for the consideration of the impact of sleep on neurocognition in people with SZ and propose recommendations for future research to elucidate the links between sleep parameters, neurocognition and daily functioning.

Alterations in TRN-anterodorsal thalamocortical circuits affect sleep architecture and homeostatic processes in oxidative stress vulnerable Gclm-/- mice

Schizophrenia is associated with alterations of sensory integration, cognitive processing and both sleep architecture and sleep oscillations in mouse models and human subjects, possibly through changes in thalamocortical dynamics. Oxidative stress (OxS) damage, including inflammation and the impairment of fast-spiking gamma-aminobutyric acid neurons have been hypothesized as a potential mechanism responsible for the onset and development of schizophrenia. Yet, the link between OxS and perturbation of thalamocortical dynamics and sleep remains unclear. Here, we sought to investigate the effects of OxS on sleep regulation by characterizing the dynamics of thalamocortical networks across sleep-wake states in a mouse model with a genetic deletion of the modifier subunit of glutamate-cysteine ligase (Gclm knockout, KO) using high-density electrophysiology in freely-moving mice. We found that Gcml KO mice exhibited a fragmented sleep architecture and impaired sleep homeostasis responses as revealed by the increased NREM sleep latencies, decreased slow-wave activities and spindle rate after sleep deprivation. These changes were associated with altered bursting activity and firing dynamics of neurons from the thalamic reticularis nucleus, anterior cingulate and anterodorsal thalamus. Administration of N-acetylcysteine (NAC), a clinically relevant antioxidant, rescued the sleep fragmentation and spindle rate through a renormalization of local neuronal dynamics in Gclm KO mice. Collectively, these findings provide novel evidence for a link between OxS and the deficits of frontal TC network dynamics as a possible mechanism underlying sleep abnormalities and impaired homeostatic responses observed in schizophrenia.

Sleep in first-episode schizophrenia patients, their unaffected siblings and healthy controls: A comparison

BACKGROUND

Sleep disturbances in schizophrenia are common throughout its course including in the prodrome, and have been mainly attributed to severity of symptoms and antipsychotic use. We aimed to investigate whether early course patients with schizophrenia and young non-psychotic siblings of patients with schizophrenia also show sleep disturbances and whether sleep correlates with symptoms and functioning.

METHODS

Three study groups, that is, adults newly diagnosed with schizophrenia (n = 54), young non-psychotic siblings of schizophrenia patients (n = 56) and a sample of healthy controls matched to the patients and siblings (n = 61) were evaluated on Horne and Ostberg Morningness-Eveningness Questionnaire, Epworth Sleepiness Scale and Pittsburgh Sleep Quality Index. Severity of symptoms and functioning are assessed using the Positive and Negative Syndrome Scale and the Global Assessment of Functioning Scale, respectively. Age, gender, occupation and marital status were regarded as covariates, and differences between the three groups were evaluated using analysis of covariance.

RESULTS

Early course schizophrenia patients and non-psychotic siblings of schizophrenia patients showed significantly reduced sleep quality relative to healthy controls (P < .001). Schizophrenia patients had significantly higher daytime sleepiness compared to controls (P < .001). Chronotypes in schizophrenia patients and unaffected siblings did not significantly differ from those of the healthy controls.

CONCLUSIONS

Like chronic medicated schizophrenia patients, early course schizophrenia patients and young non-psychotic siblings of individuals with schizophrenia have sleep disturbances. These findings indicate that sleep markers can distinguish unaffected siblings of schizophrenia from healthy controls and serve as an endophenotype for schizophrenia.

The association between sleep disturbances and negative symptom severity in patients with non-affective psychotic disorders, unaffected siblings and healthy controls

Sleep disturbances in patients with psychotic disorders are common and associated with poor clinical outcomes, but research on negative symptoms is limited. This study aimed to examine the association between subjective sleep disturbances and negative symptoms in 525 patients with non-affective psychotic disorders, 569 unaffected siblings and 265 healthy controls (HC) from the Genetic Risk and Outcome of Psychosis (GROUP) study. Several aspects of subjective sleep disturbances were assessed: sleep satisfaction, sleep onset insomnia, midnocturnal insomnia, early morning insomnia, and hypersomnia. Regression analyses revealed significant negative associations between sleep satisfaction and negative symptoms in all three groups. In addition, significant associations with sleep onset insomnia and hypersomnia were found in patients and with early morning insomnia and hypersomnia in siblings. Exploratory mediation analyses showed that depressive symptoms partly mediated all associations on the subclinical level in siblings and healthy controls, whereas only the association with sleep onset insomnia was mediated in patients. The results of this study implicate specific sleep disturbances and depressive symptoms as potential targets in prevention or intervention strategies focussed on negative symptoms in individuals suffering from, or at risk of non-affective psychotic disorders.

Sleep disturbances and the At Risk Mental State: A systematic review and meta-analysis

AIMS

To synthesise and investigate how sleep disturbances relate to psychotic symptoms, functioning and Quality of Life (QoL) in At Risk Mental State (ARMS) youth.

METHOD

A comprehensive search of six databases (MEDLINE, PsycINFO, Embase, CINAHL, Web of Science and CENTRAL) was conducted. Eligible studies provided data on sleep disturbances or disorders in ARMS patients.

RESULTS

Sixteen studies met the inclusion criteria (n = 1962 ARMS patients) including 7 cross-sectional studies, 2 RCT's and 7 cohort studies. Narrative synthesis revealed that self-reported sleep (e.g., general disturbances, fragmented night time sleep and nightmares) was poorer among ARMS patients compared to healthy controls. In the limited studies (n = 4) including objective measurements of sleep disturbances, ARMS patients experienced higher levels of movement during sleep, more daytime naps and increased sleep latency compared to controls. Furthermore, sleep disturbances were associated with attenuated psychotic symptoms and functional outcomes cross-sectionally and longitudinally. Only one study investigated the relationship between sleep and QoL. The exploratory meta-analysis revealed a significant difference in self-reported sleep disturbances measured by the PSQI (mean difference in score: 3.30 (95% CI 1.87, 4.74), p < 0.00001) and SIPS (mean difference in score: 1.58 (95% CI 0.80, 2.35), p < 0.00001) of ARMS patients compared to control groups.

CONCLUSIONS

ARMS individuals report impaired sleep quality and reduced sleep quantity compared to healthy controls. However, further research is needed to explore the longitudinal relationship between sleep disruptions and QoL in early psychosis. Significant variations in how sleep is measured across studies highlight a need to assess disturbances to sleep using robust and consistent approaches in this patient group.

Expanding the search for emerging mental ill health to safeguard student potential and vocational success in high school: A narrative review

AIM

Young people experiencing mental ill health are more likely than their healthy aged peers to drop out of high school. This can result in social exclusion and vocational derailment. Identifying young people at risk and taking action before an illness is established or school dropout occurs is an important goal. This study aimed to examine evidence for the risk markers and at risk mental states of the clinical staging model (stage 0-1b) and whether these risk states and early symptoms impact school participation and academic attainment.

METHOD

This narrative review assembles research from both the psychiatry and education literature. It examines stage 0 to stage 1b of the clinical staging model and links the risk states and early symptoms to evidence about the academic success of young people in high school.

RESULTS

In accordance with the clinical staging model and evidence from education literature, childhood trauma and parental mental illness can impact school engagement and academic progress. Sleep disturbance can result in academic failure. Undifferentiated depression and anxiety can increase the risk for school dropout. Subthreshold psychosis and hypomanic states are associated with functional impairment and high rates of Not in Employment, Education, or Training (NEET) but are not recognized in the education literature.

CONCLUSION

Risk markers for emerging mental ill health can be identified in education research and demonstrate an impact on a student's success in high school. Clear referral protocols need to be embedded into school life to reduce risk of progression to later stages of illness and support school participation and success.

Community Psychosis Risk Screening: An Instrument Development Investigation

Schizophrenia and other psychotic disorders are serious psychiatric disorders that are associated with substantial societal, family, and individual costs/distress. Evidence suggests that early intervention can improve prognostic outcomes; therefore, it is essential to accurately identify those at risk for psychosis before full psychotic symptoms emerge. The purpose of our study is to develop a brief, valid screening questionnaire to identify individuals at risk for psychosis in non-clinical populations across 3 large, community catchment areas with diverse populations. This is a needed study, as the current screening tools for at-risk psychotic populations in the US have been validated only in clinical and/or treatment seeking samples, which are not likely to generalize beyond these specialized settings. The specific aims are as follows: (1) to determine norms and prevalence rates of attenuated positive psychotic symptoms across 3 diverse, community catchment areas and (2) to develop a screening questionnaire, inclusive of both symptom-based and risk factor-based questions. Our study will develop an essential screening tool that will identify which individuals have the greatest need of follow-up with structured interviews in both research and clinical settings. Our study has the potential for major contributions to the early detection and prevention of psychotic disorders.

Are Circadian Disturbances a Core Pathophysiological Component of Schizophrenia?

Schizophrenia is a multifactorial disorder caused by a combination of genetic variations and exposure to environmental insults. Sleep and circadian rhythm disturbances are a prominent and ubiquitous feature of many psychiatric disorders, including schizophrenia. There is growing interest in uncovering the mechanistic link between schizophrenia and circadian rhythms, which may directly affect disorder outcomes. In this review, we explore the interaction between schizophrenia and circadian rhythms from 2 complementary angles. First, we review evidence that sleep and circadian rhythm disturbances constitute a fundamental component of schizophrenia, as supported by both human studies and animal models with genetic mutations related to schizophrenia. Second, we discuss the idea that circadian rhythm disruption interacts with existing risk factors for schizophrenia to promote schizophrenia-relevant behavioral and neurobiological abnormalities. Understanding the mechanistic link between schizophrenia and circadian rhythms will have implications for mitigating risk to the disorder and informing the development of circadian-based therapies.

Sleep disturbances in youth at-risk for serious mental illness

AIM

To investigate sleep behaviours of youth at-risk for serious mental illness (SMI).

METHODS

This study included 243 youth, ages 12 to 25:42 healthy controls, 41 asymptomatic youth at-risk for mental illness (stage 0); 53 help-seeking youth experiencing distress (stage 1a) and 107 youth with attenuated syndromes (stage 1b). The Pittsburgh Sleep Quality Index was used to assess sleep dysfunction.

RESULTS

Stage 1b individuals indicated the greatest deficit in global sleep dysfunction (F = 26.18, P < .0001). Stages 1a and 1b reported significantly worse subjective sleep quality, a longer sleep latency, increased use of sleep medications as well as greater daytime dysfunction compared to the asymptomatic groups.

CONCLUSION

Research investigating sleep behaviours of youth considered to be at-risk for SMI is limited. This study provides early evidence that sleep disturbances are worse for individuals considered to be at higher risk of illness development.

Sleep therapeutics and neuropsychiatric illness

Alterations in sleep are extremely common in patients with neuropsychiatric illness. In addition, sleep disorders such as insomnia, obstructive sleep apnea, rapid eye movement sleep behavior disorder, and circadian rhythm disorders commonly occur at a rate greater than the general population in neuropsychiatric conditions. Historically, sleep problems have been viewed as symptoms of associated neuropsychiatric disorders. However, there is increasing evidence suggesting a complex inter-relationship with possible bidirectional causality. The inter-relatedness of these conditions represents an opportunity for understanding mechanisms and improving clinical treatment. To the extent that sleep problems affect neuropsychiatric conditions, it may be possible to address sleep problems and have a positive impact on the course of neuropsychiatric illnesses. Further, some treatments for sleep disorders have direct effects on neuropsychiatric illnesses that may be unrelated to their effects on sleep disorders. Similarly, neuropsychiatric conditions and their treatments can affect sleep and sleep disorders. This article reviews available evidence on the effects of therapies for sleep disorders on neuropsychiatric conditions and also secondarily considers the impacts of therapies for neuropsychiatric conditions on sleep. Primary goals of this review are to identify gaps in current research, to determine the extent to which the cross-therapeutic effects of these treatments help to elucidate therapeutic or pathological mechanisms, and to assist clinicians in optimizing therapeutic choice in patients with sleep disorders and neuropsychiatric conditions.

Sleep disturbances in schizophrenia spectrum and bipolar disorders - a transdiagnostic perspective

BACKGROUND

Sleep disturbances are prevalent in severe mental disorders but their type and frequency across diagnostic categories has not been investigated in large scale studies.

METHODS

Participants with Schizophrenia spectrum disorders (SCZ, (N = 617)), Bipolar disorders (BD, (N = 440)), and Healthy Controls (HC, (N = 173)) were included in the study. Sleep disturbances (insomnia, hypersomnia and delayed sleep phase) were identified based on items from the Inventory of Depressive Symptoms - Clinician rated scale. Clinical symptoms were assessed with the Positive and Negative Syndrome scale and level of functioning with the Global assessment of Functioning scale.

RESULTS

The rate of any sleep disturbance was 78% in SZ, 69% in BD and 39% in HC. Insomnia was the most frequently reported sleep disturbance across all groups. Both diagnostic groups reported significantly more of any sleep disturbances than HC (P < 0.001). Having a sleep disturbance was associated with more severe negative and depressive symptoms and with lower functioning across diagnostic groups (P < 0.001, η² = 0.0071). Hypersomnia was the only sleep disturbance associated with previous treatment history.

CONCLUSION

Sleep disturbances, including insomnia, hypersomnia and delayed sleep phase, are frequent in SCZ and BD, and associated with more severe clinical symptomatology across diagnostic groups. This suggests that sleep disturbance is a clinically relevant transdiagnostic phenomenon.

The effect of cognitive behavioral therapy for insomnia in schizophrenia patients with sleep Disturbance: A non-randomized, assessor-blind trial

This non-randomized, assessor blind study evaluated the effects of cognitive behavioral therapy for insomnia (CBT-I) delivered in a group format on insomnia symptoms as well as psychotic, depressive, and anxiety symptoms in schizophrenia patients (n = 63) recruited from residential or rehabilitative facilities in Seoul, South Korea. Thirty-one patients received four sessions of CBT-I in groups of 2-9 patients in addition to usual care, while the control group (n = 32) received no additional intervention. The Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI), Psychotic Symptoms Rating Scale (PSYRATS), Anxiety Sensitivity Index (ASI), and Beck Depression Inventory (BDI) were administered at baseline, week 4, and week 8. Both groups showed significant time-group interactions on the ISI and PSQI. Post hoc testing showed that, compared to the control group, the CBT-I group showed significant reductions in ISI and PSQI at both week 4 and week 8. For the PSYRATS, ASI, and BDI scores, the CBT-I and control groups showed significant time-group interactions, but post hoc testing revealed no significant group differences at either week 4 or week 8. Therefore, CBT-I was effective for reducing insomnia symptoms in patients with schizophrenia and the effect lasted for 4 weeks after the intervention.

Does exercise improve sleep quality in individuals with mental illness? A systematic review and meta-analysis

People living with mental illness often experience poor sleep quality compared to the general population. Poor sleep quality exacerbates symptoms of mental illness and contributes to increased physical comorbidities. Exercise has been shown to be an effective non-pharmacological treatment for managing poor sleep in the general population. Little is known regarding the efficacy of targeted exercise interventions for improving sleep quality amongst individuals with a mental illness. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) examining the impact of exercise on sleep quality in people with mental illness. Major electronic databases were searched from inception until June 2018 for exercise-based RCTs that included either subjective and/or objective measures of sleep quality in people with severe mental illness (SMI). Eight RCT's were included in the meta-analysis, involving use of a range of exercise modalities in people with SMI diagnoses. Overall, exercise had a large statistically significant effect on sleep quality (hedges g = 0.73, 95% CI; (0.18, 1.28), p-value = 0.01; N = 8, n = 1,329, I² = 91.15%). The beneficial effect of exercise on sleep quality outlined in this study highlights the important role exercise has in improving health outcomes for people living with mental illness. Further research is required to determine the efficacy of exercise on sleep in people experiencing a psychiatric illness and to explore the effects of exercise intervention elements such as modality, frequency, intensity and delivery settings.

Sleep duration and psychotic experiences in patients at risk of psychosis: A secondary analysis of the EDIE-2 trial

Sleep disturbance is common among individuals at risk of psychosis, yet few studies have investigated the relationship between sleep disturbance and clinical trajectory. The Early Detection and Intervention Evaluation (EDIE-2) trial provides longitudinal data on sleep duration and individual psychotic experiences from a cohort of individuals at risk of psychosis, which this study utilises in an opportunistic secondary analysis. Shorter and more variable sleep was hypothesised to be associated with more severe psychotic experiences and lower psychological wellbeing. Mixed effect models were used to test sleep duration and range as predictors of individual psychotic experiences and psychological wellbeing over the 12-24 months (with assessments every 3 months) in 160 participants. Shorter sleep duration was associated with more severe delusional ideas and hallucinations cross-sectionally and longitudinally. The longitudinal relationships did not remain significant after conservative controls were added for the previous severity of psychotic experiences. No significant relationships were found between the sleep variables and other psychotic experiences (e.g. cognitive disorganisation), or psychological wellbeing. The results support a relationship between shorter sleep duration and delusional ideas and hallucinations. Future studies should focus on improving sleep disturbance measurement, and test whether treating sleep improves clinical trajectory in the at-risk group.

Sleep, circadian rhythms, and schizophrenia: where we are and where we need to go

PURPOSE OF REVIEW

The review is designed to give an overview of the latest developments in research exploring the relationship between sleep and psychosis, with particular attention paid to the evidence for a causal relationship between the two.

RECENT FINDINGS

The most interesting avenues currently in pursuit are focused upon sleep spindle deficits which may hallmark an endophenotype; explorations of the continuum of psychotic experiences, and experimental manipulations to explore the evidence for bidirectional causality; inflammatory markers, psychosis and sleep disturbances and finally, treatment approaches for sleep in psychosis and the subsequent impact on positive experiences.

SUMMARY

Globally, large surveys and tightly controlled sleep deprivation or manipulation experiments provide good evidence for a cause-and-effect relationship between sleep and subclinical psychotic experiences. The evidence for cause-and-effect using a interventionist-causal model is more ambiguous; it would appear treating insomnia improves psychotic experiences in an insomnia cohort but not in a cohort with schizophrenia. This advocates the necessity for mechanism-driven research with dimensional approaches and in depth phenotyping of circadian clock-driven processes and sleep regulating functions. Such an approach would lead to greater insight into the dynamics of sleep changes in healthy and acute psychosis brain states.

What Can Happen When Postpartum Anxiety Progresses to Psychosis? A Case Study

This case report describes a primipara without documented psychiatric history prior to complicated delivery. Onset of severe insomnia and anxiety was right after childbirth but not treated. Obsessive thinking pattern became more prominent. The patient became depressed and sought psychiatric help four months after delivery. Insomnia was then treated pharmacologically. Anxiety and depression persisted, suicidal ideation emerged, and the patient became confused, indecisive, overwhelmed, and delusional regarding her child's health. Medications for depression and anxiety were started six months postpartum yet were ineffective. The patient's obsessions gradually became fully psychotic and she committed an altruistic infanticide eight months postpartum. Psychiatric hospitalization occurred, followed by a long course of mental, physical, legal, and social rehabilitation. She was minimally responsive to psychopharmacological treatment, which appeared to be partly related to her hormonal dysregulation. Several months into the treatment she gradually started improving and returned to baseline two years later. The Illinois court found the patient not guilty to murder by reason of Insanity.

Genetic Variations Associated with Sleep Disorders in Patients with Schizophrenia: A Systematic Review

Background: Schizophrenic patients commonly suffer from sleep disorders which are associated with acute disease severity, worsening prognoses and a poorer quality of life. Research is attempting to disentangle the complex interplay between schizophrenia and sleep disturbances by focusing not only on demographic and clinical characteristics, but also on the identification of genetic factors. Methods: Here, we performed a systematic literature review on the topic of genetic variations in sleep-disordered schizophrenic patients in an attempt to identify high quality investigations reporting scientifically sound and clinically useful data. For this purpose, we conducted a thorough search of PubMed, ScienceDirect and GoogleScholar databases, according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocol. Results: Our search yielded 11 eligible studies. Certain genetic variations were reported to be associated with schizophrenia-related sleep disorders. Antipsychotic-induced restless legs syndrome was linked to polymorphisms located on CLOCK, BTBD9, GNB3, and TH genes, clozapine-induced somnolence was correlated with polymorphisms of HNMT gene, while insomnia was associated with variants of the MTNR1 gene. Conclusions: There are significant genetic associations between schizophrenia and co-morbid sleep disorders, implicating the circadian system, dopamine and histamine metabolism and signal transduction pathways.

The interaction between subclinical psychotic experiences, insomnia and objective measures of sleep

Investigations into schizophrenia have revealed a high incidence of comorbidity with disturbed sleep and circadian timing. Acknowledging this comorbidity on a dimensional level, we tested prospectively whether subclinical psychotic symptoms are more prevalent in individuals with insomnia. An insomnia group (n=21) and controls (n=22) were recruited on their subjective sleep quality, recorded actigraphically for 3weeks and assessed for psychotic-like experiences with The Prodromal Questionnaire-16. Using multivariate Poisson regression analyses, we found that objective and subjective sleep measures interact to predict the highest risk for psychotic experiences. Objective measures of sleep and statistical modelling are rarely used in either clinical trials or practice for schizophrenia, yet this study highlights their value in these areas.

Sleep spindles and slow waves in schizophrenia and related disorders: main findings, challenges and future perspectives

Sleep abnormalities have recently gained renewed attention in patients diagnosed with schizophrenia. Disrupted thalamocortical brain oscillations hold promise as putative biomarkers or endophenotypes of the disorder. Despite an increase in studies related to sleep spindle and slow-wave activity, findings remain in part contradictory. Although sleep spindle deficits have been confirmed in several groups of patients with chronic, medicated schizophrenia, data on the early stages of the disorder and in unmedicated subjects are still insufficient. Findings on slow-wave abnormalities are largely inconclusive, possibly due to the different criteria employed to define the phenomenon and to the influence of atypical antipsychotics. In this review, we aim to address the methodological and practical issues that may have limited the consistency of findings across research groups and different patient populations. Given the neurobiological relevance of these oscillations, which reflect the integrity of thalamocortical and cortico-cortical function, research in this domain should be encouraged. To promote widespread consensus over the scientific and clinical implications of these sleep-related phenomena, we advocate uniform and sound methodological approaches. These should encompass electroencephalographic recording and analysis techniques but also selection criteria and characterization of clinical populations.

Cognitive Behavioral Therapy for Insomnia as Adjunctive Therapy to Antipsychotics in Schizophrenia: A Case Report

The authors present the case of a 38-year-old man with schizophrenia and with severe insomnia, who attempted suicide twice during oral drug therapy with risperidone. The patient slept barely 2 or 3 h per night, and he frequently took half days off from work due to excessive daytime sleepiness. As a maladaptive behavior to insomnia, he progressively spent more time lying in bed without sleeping, and he repeatedly thought about his memories, which were reconstructed from his hallucinations. His relatives and friends frequently noticed that his memories were not correct. Consequently, the patient did not trust his memory, and he began to think that the hallucinations controlled his life. During his insomniac state, he did not take antipsychotic drugs regularly because of his irregular meal schedule due to his excessive daytime sleepiness. The authors started cognitive behavioral therapy for insomnia (CBT-i) with aripiprazole long acting injection (LAI). CBT-i is needed to be tailored to the patient's specific problems, as this case showed that the patient maladaptively use chlorpromazine as a painkiller, and he exercised in the middle of the night because he believed he can fall asleep soon after the exercise. During his CBT-i course, he learned how to evaluate and control his sleep. The patient, who originally wanted to be short sleeper, began to understand that adequate amounts of sleep would contribute to his quality of life. He finally stopped taking chlorpromazine and benzodiazepine as sleeping drugs while taking suvorexant 20 mg. Through CBT-i, he came to understand that poor sleep worsened his hallucinations, and consequently made his life miserable. He understood that good sleep eased his hallucinations, ameliorated his daytime sleepiness and improved his concentration during working hours. Thus, he was able to improve his self-esteem and self-efficacy by controlling his sleep. In this case report, the authors suggest that CBT-i can be an effective therapy for schizophrenia patients with insomnia to the same extent of other psychiatric and non-psychiatric patients.

Psychosis as an Evolutionary Adaptive Mechanism to Changing Environments

Background: From an evolutionary perspective it is remarkable that psychotic disorders, mostly occurring during fertile age and decreasing fecundity, maintain in the human population. Aim: To argue the hypothesis that psychotic symptoms may not be viewed as an illness but as an adaptation phenomenon, which can become out of control due to different underlying brain vulnerabilities and external stressors, leading to social exclusion. Methods: A literature study and analysis. Results: Until now, biomedical research has not unravelld the definitive etiology of psychotic disorders. Findings are inconsistent and show non-specific brain anomalies and genetic variation with small effect sizes. However, compelling evidence was found for a relation between psychosis and stressful environmental factors, particularly those influencing social interaction. Psychotic symptoms may be explained as a natural defense mechanism or protective response to stressful environments. This is in line with the fact that psychotic symptoms most often develop during adolescence. In this phase of life, leaving the familiar, and safe home environment and building new social networks is one of the main tasks. This could cause symptoms of "hyperconsciousness" and calls on the capacity for social adaptation. Conclusions: Psychotic symptoms may be considered as an evolutionary maintained phenomenon.Research investigating psychotic disorders may benefit from a focus on underlying general brain vulnerabilities or prevention of social exclusion, instead of psychotic symptoms.

Self-reported sleep disturbances associated with procedural learning impairment in adolescents at ultra-high risk for psychosis

Sleep disturbance contributes to impaired procedural learning in schizophrenia, yet little is known about this relationship prior to psychosis onset. Adolescents at ultra high-risk (UHR; N=62) for psychosis completed the Pittsburgh Sleep Quality Index (PSQI) and a procedural learning task (Pursuit Rotor). Increased self-reported problems with sleep latency, efficiency, and quality were associated with impaired procedural learning rate. Further, within-sample comparisons revealed that UHR youth reporting better sleep displayed a steeper learning curve than those with poorer sleep. Sleep disturbances appear to contribute to cognitive/motor deficits in the UHR period and may play a role in psychosis etiology.

Childhood trauma, depression, and sleep quality and their association with psychotic symptoms and suicidality in schizophrenia

This study involved the examination of the relationship between childhood trauma and both psychotic symptoms and suicidality in patients with schizophrenia after controlling for the possible confounding factors, such as clinical features, depression, and sleep quality. The Childhood Trauma Questionnaire-Short Form, Positive and Negative Syndrome Scale (PANSS), Calgary Depression Scale for Schizophrenia (CDSS), Pittsburgh Sleep Quality Index (PSQI), and the suicidality subscale of Mini-International Neuropsychiatric Interview (MINI) were administered to 199 patients with schizophrenia. We used sequential multiple stepwise regression analyses in which positive symptoms, negative symptoms, overall psychopathology, total symptoms of schizophrenia, and suicidality were dependent variables. Depressive symptomatology and childhood physical abuse significantly contributed to positive, negative, general psychopathology, and global schizophrenia symptomatology. Interestingly, general psychopathology scores were negatively associated with childhood physical neglect. Also, subjective sleep quality significantly contributed to positive schizophrenia symptoms. Although prior suicide attempts and depression were significant antecedents of suicidal ideation, no association between suicidality and both childhood trauma and sleep was found. Childhood physical abuse could have an impact on psychopathology in schizophrenia. In addition to childhood trauma, depression, sleep disturbances, and clinical features should be considered and inquired about in the course of clinical care of schizophrenia patients.

Adolescents at clinical-high risk for psychosis: Circadian rhythm disturbances predict worsened prognosis at 1-year follow-up

BACKGROUND

Individuals with psychotic disorders experience disruptions to both the sleep and circadian components of the sleep/wake cycle. Recent evidence has supported a role of sleep disturbances in emerging psychosis. However, less is known about how circadian rhythm disruptions may relate to psychosis symptoms and prognosis for adolescents with clinical high-risk (CHR) syndromes. The present study examines circadian rest/activity rhythms in CHR and healthy control (HC) youth to clarify the relationships among circadian rhythm disturbance, psychosis symptoms, psychosocial functioning, and the longitudinal course of illness.

METHODS

Thirty-four CHR and 32 HC participants were administered a baseline evaluation, which included clinical interviews, 5days of actigraphy, and a sleep/activity diary. CHR (n=29) participants were re-administered clinical interviews at a 1-year follow-up assessment.

RESULTS

Relative to HC, CHR youth exhibited more fragmented circadian rhythms and later onset of nocturnal rest. Circadian disturbances (fragmented rhythms, low daily activity) were associated with increased psychotic symptom severity among CHR participants at baseline. Circadian disruptions (lower daily activity, rhythms that were more fragmented and/or desynchronized with the light/dark cycle) also predicted severity of psychosis symptoms and psychosocial impairment at 1-year follow-up among CHR youth.

CONCLUSIONS

Circadian rhythm disturbances may represent a potential vulnerability marker for emergence of psychosis, and thus, rest/activity rhythm stabilization has promise to inform early-identification and prevention/intervention strategies for CHR youth. Future studies with longer study designs are necessary to further examine circadian rhythms in the prodromal period and rates of conversion to psychosis among CHR teens.

Schizophrenia and sleep disorders: links, risks, and management challenges

Schizophrenia is a major psychiatric disorder that has a massive, long-lasting negative impact on the patients as well as society. While positive symptoms (i.e., delusions and hallucinations), negative symptoms (i.e., anhedonia, social withdrawal), and cognitive impairments are traditionally considered the most prominent features of this disorder, the role of sleep and sleep disturbances has gained increasing prominence in clinical practice. Indeed, the vast majority of patients with schizophrenia report sleep abnormalities, which tend to precede illness onset and can predict an acute exacerbation of psychotic symptoms. Furthermore, schizophrenia patients often have a comorbid sleep disorder, including insomnia, obstructive sleep apnea, restless leg syndrome, or periodic limb movement disorder. Despite accumulating data, the links between sleep disorders and schizophrenia have not been thoroughly examined, in part because they are difficult to disentangle, as numerous factors contribute to their comorbidity, including medication status. Additionally, sleep disorders are often not the primary focus of clinicians treating this population, despite studies suggesting that comorbid sleep disorders carry their own unique risks, including worsening of psychotic symptoms and poorer quality of life. There is also limited information about effective management strategies for schizophrenia patients affected by significant sleep disturbances and/or sleep disorders. To begin addressing these issues, the present review will systematically examine the literature on sleep disorders and schizophrenia, focusing on studies related to 1) links between distinct sleep disorders and schizophrenia; 2) risks unique to patients with a comorbid sleep disorder; and 3) and management challenges and strategies.

Sleep and circadian alterations in people at risk for bipolar disorder: A systematic review

BACKGROUND

Sleep and circadian abnormalities have been mostly demonstrated in bipolar patients. However, it is not clear whether these alterations are present in population at high risk for bipolar disorder (BD), indicating a possible risk factor for this condition.

OBJECTIVE

This systematic review aims to define current evidence about sleep and rhythm alterations in people at risk for BD and to evaluate sleep and circadian disorders as risk factor for BD.

METHODS

The systematic review included all articles about the topic until February 2016. Two researchers performed an electronic search of PubMed and Cochrane Library. Keywords used were 'sleep' or 'rhythm' or 'circadian' AND 'bipolar disorder' or 'mania' or 'bipolar depression' AND 'high-risk' or 'risk'.

RESULTS

Thirty articles were analyzed (7451 participants at risk for BD). Sleep disturbances are frequent in studies using both subjective measures and actigraphy. High-risk individuals reported irregularity of sleep/wake times, poor sleep and circadian rhythm disruption. Poor sleep quality, nighttime awakenings, and inadequate sleep are possible predictive factors for BD. A unique study suggested that irregular rhythms increase risk of conversion. People at risk for BD showed high cortisol levels in different times of day. Studies about anatomopathology, melatonin levels, inflammatory cytokines and oxidative stress were not identified. The most important limitations were differences in sleep and rhythm measures, heterogeneity of study designs, and lack of consistency in the definition of population at risk.

CONCLUSION

Sleep and circadian disturbances are common in people at risk for BD. However, the pathophysiology of these alterations and the impact on BD onset are still unclear.

Increased sleep duration precedes the improvement of other symptom domains during the treatment of acute mania: a retrospective chart review

BACKGROUND

Understanding trajectories of symptom changes may help gauge treatment response and better identify therapeutic targets in treatment of acute mania. We examined how symptoms of sleep disturbance, mania, and psychosis resolved in a naturalistic treatment setting, hypothesizing that improvement in sleep would precede improvement in manic and psychotic symptoms.

METHODS

Charts of 100 patients with admitting diagnoses of bipolar mixed or manic episode were retrospectively reviewed. Medications and demographic variables were recorded, and the Clinician-Administered Rating Scale for Mania (CARS-M) mania and psychosis ratings and sleep hours were determined for 8 observation points. Times to minimum symptom level in each domain were compared via Wilcoxon signed-rank tests. Symptom correlations and trajectories and medication effects were explored using repeated measures ANOVA and regression models.

RESULTS

Manic and psychotic symptom resolution was linear over the time of hospitalization. In contrast, sleep showed a slow initial response, followed by rapid increase to peak, preceding peak improvement in mania and psychosis (p < 0.001). Rate of sleep restoration was a predictor of rate but not of magnitude of treatment response for symptoms mania and psychosis. Patterns of medication use did not affect symptom trajectories.

CONCLUSIONS

In acute mania, improvement in sleep with treatment is dissociable from resolution in symptoms of mania and psychosis, but there appears to be no therapeutic advantage to patient oversedation. Sleep improves first and may be both a predictor of the rate of treatment response and a useful therapeutic target.

A systematic review of the nature and correlates of sleep disturbance in early psychosis

Sleep disturbances are common in people with a diagnosis of schizophrenia and have been associated with increased symptom severity, neurocognitive deficits and reduced quality of life. Despite a significant body of literature in this field, there has been limited investigation of sleep disturbance in the early course of the illness. This systematic review aims to synthesise and evaluate the available data exploring sleep in early psychosis, with two key research questions: 1) What is the nature of sleep disturbance in early psychosis? and 2) What are the correlates of sleep disturbance in early psychosis? From an initial search, 16,675 papers were identified, of which 21 met inclusion/exclusion criteria. The preliminary evidence suggests that self-reported sleep disturbances are prevalent in early psychosis and may be associated with symptom severity, as well as elevated rates of both help-seeking and suicidality. Abnormalities in sleep architecture and sleep spindles are also commonly observed and may correlate with symptom severity and neurocognitive deficits. However, due to significant methodological limitations and considerable heterogeneity across studies, evidence to support the reliability of these associations is limited. We outline a research agenda, emphasising the prospective use of gold-standard sleep measurement to investigate the prevalence and nature of sleep disturbances in early psychosis, as well as how these may be related to the onset and persistence of psychotic symptoms.

Abnormalities in sleep patterns in individuals at risk for psychosis and bipolar disorder

AIM

To compare patterns of sleep and the presence of sleep disturbances in individuals in at-risk mental states (ARMS) for psychosis and bipolar disorder (BD) with a healthy control (HC) group.

METHODS

This was a comparative study involving 20 individuals in ARMS for psychosis or BD, according to the Comprehensive Assessment of At-Risk Mental States, and 20 age- and sex-matched healthy controls. Quality of sleep in the previous month was assessed using the Pittsburgh Sleep Quality Index, diurnal somnolence was evaluated using The Epworth Sleepiness Scale, and chronotype was determined using the Questionnaire of Morningness/Eveningness (QME). All of the participants underwent polysomnography (PSG) during the entire night for two consecutive nights. The first night aimed to adapt the subject to the environment, and only the data from the second night were used for the analysis.

RESULTS

Compared with the HC group, individuals in the ARMS group reported significantly worse sleep quality, as measured by the Pittsburgh Sleep Quality Index. Both groups had scores consistent with daytime sleepiness on the Epworth Sleepiness Scale, and there were no differences with regard to chronotype between the groups, with a predominance of the indifferent type in both groups. In the PSG assessment, we observed increased Sleep Latency (SL) and increased Rapid Eye Movement Sleep Onset Latency (REMOL) in the ARMS group, compared to the HC group.

CONCLUSION

The results of this study indicated that sleep abnormalities could be found early in the course of mental diseases, even in at-risk stages, and support the further investigation of their predictive value in the transition to psychosis and BD.

The role of sleep dysfunction in the occurrence of delusions and hallucinations: A systematic review

BACKGROUND

Sleep dysfunction is extremely common in patients with schizophrenia. Recent research indicates that sleep dysfunction may contribute to psychotic experiences such as delusions and hallucinations.

OBJECTIVES

The review aims to evaluate the evidence for a relationship between sleep dysfunction and individual psychotic experiences, make links between the theoretical understanding of each, and highlight areas for future research.

METHOD

A systematic search was conducted to identify studies investigating sleep and psychotic experiences across clinical and non-clinical populations.

RESULTS

66 papers were identified. This literature robustly supports the co-occurrence of sleep dysfunction and psychotic experiences, particularly insomnia with paranoia. Sleep dysfunction predicting subsequent psychotic experiences receives support from epidemiological surveys, research on the transition to psychosis, and relapse studies. There is also evidence that reducing sleep elicits psychotic experiences in non-clinical individuals, and that improving sleep in individuals with psychosis may lessen psychotic experiences. Anxiety and depression consistently arise as (partial) mediators of the sleep and psychosis relationship.

CONCLUSION

Studies are needed that: determine the types of sleep dysfunction linked to individual psychotic experiences; establish a causal connection between sleep and psychotic experiences; and assess treatments for sleep dysfunction in patients with non-affective psychotic disorders such as schizophrenia.

Sleep Disorders Among People With Schizophrenia: Emerging Research

Up to 80 % of individuals with schizophrenia spectrum disorders experience sleep disturbances, which impact physical and mental health, as well as quality of life. In this paper, we review and integrate emerging literature, published between 2012 and 2014, regarding approaches to diagnosis and treatment of major sleep disorders for people with schizophrenia spectrum disorders, including insomnia, obstructive sleep apnea (OSA), circadian rhythm dysfunction, and restless legs syndrome (RLS). We advocate for (1) the need to evaluate the utility of nonpharmacological approaches in people with schizophrenia spectrum disorders; (2) documentation of guidelines to assist providers in clinically tailoring such interventions when their clients experience positive, negative, and/or cognitive symptoms; (3) research on the best ways providers can capitalize on clients' self-identified needs and motivation to engage in sleep treatments through shared decision making; and (4) the importance of investigating whether and how mental health and sleep treatment services should be better connected to facilitate access for people with schizophrenia spectrum disorders. Assessment and tailored treatment of sleep disorders within mental health treatment settings has the potential to reduce sleep problems and improve functioning, quality of life, and recovery of this population.

The impact of assertive outreach teams on hospital admissions for psychosis: a time series analysis

Although the assertive outreach model was developed in the United States and imported to the United Kingdom to date, there is only limited evidence to support its wide-scale implementation within the United Kingdom. This is the first study to have combined a large dataset with this type of research method to explore the impact of assertive outreach teams on hospital admissions. The introduction and expansion of assertive outreach teams was associated with reducing hospital admissions for people with psychosis. This study found a consistent summer peak in hospital admissions which community and in-patient mental health nurses should take account of and plan for. Ever since the Mental Health Policy Implementation Policy Guide paved the way for the introduction of the Assertive Outreach Treatment (AOT) model in England, the impact of this approach has been the subject of considerable debate but limited evaluation. To date, most of the evidence supporting this model has originated from outside the United Kingdom. A central aim of the AOT was to reduce the need for in-patient treatment. We aimed to assess the impact of the AOT model on hospital admissions for people with psychosis in England. Interrupted time series analysis was used in this study to evaluate the impact of the policy change. Following the introduction of the AOT model, a statistically significant reduction in hospital admissions for psychosis was found. In addition, we observed a repeated, annual summer peak in admissions. This study adds to the international evidence which supports the effectiveness of the AOT model in reducing hospital admissions for people with severe mental health problems. We offer five suggested implications for mental health nurses and clients based on our findings.

The relationship between sleep and postpartum mental disorders: A systematic review

BACKGROUND

Postpartum mental disorders (e.g., anxiety, depression, psychosis) are serious conditions that affect approximately 10-15% of women after childbirth, and up to 40% of women at risk for these disorders. Research reveals an association between poor sleep quality/quantity and symptoms of anxiety, depression and psychosis. The aim of this systematic review was to evaluate the available evidence for the relationship between sleep and postpartum mental disorders.

METHODS

Searches included MEDLINE, EMBASE, and EBM Reviews - Cochrane Central Register of Controlled Trials, PsycINFO and EBSCOHost CINAHL through June 30, 2014. Manual searching was performed on reference lists of included articles. Published primary research in any language was included.

RESULTS

There were 3187 unique titles/abstracts and 44 full-text articles reviewed. Thirty-one studies were included. Evidence was found for the impact of self-reported poor sleep during pregnancy and the postpartum on the development of postpartum depression, with not enough evidence for either postpartum anxiety or psychosis. The evidence for objectively assessed sleep and the development of postpartum disorders was mixed. Among the 31 studies included, 1 was strong, 13 were moderate and 17 were weak.

LIMITATIONS

Research design, method of assessment, timing of assessment, recruitment strategies, representative adequacy of the samples and inclusion/exclusion criteria all varied widely. Many studies did not use tools validated for the perinatal population and had small sample sizes without power analysis.

CONCLUSIONS

Sleep interventions represent a potential low-cost, non-pharmacological prevention and treatment strategy for postpartum mental illness. Further high-quality research is needed on this topic area.

Circadian dysregulation of clock genes: clues to rapid treatments in major depressive disorder

Conventional antidepressants require 2-8 weeks for a full clinical response. In contrast, two rapidly acting antidepressant interventions, low-dose ketamine and sleep deprivation (SD) therapy, act within hours to robustly decrease depressive symptoms in a subgroup of major depressive disorder (MDD) patients. Evidence that MDD may be a circadian-related illness is based, in part, on a large set of clinical data showing that diurnal rhythmicity (sleep, temperature, mood and hormone secretion) is altered during depressive episodes. In a microarray study, we observed widespread changes in cyclic gene expression in six regions of postmortem brain tissue of depressed patients matched with controls for time-of-death (TOD). We screened 12 000 transcripts and observed that the core clock genes, essential for controlling virtually all rhythms in the body, showed robust 24-h sinusoidal expression patterns in six brain regions in control subjects. In MDD patients matched for TOD with controls, the expression patterns of the clock genes in brain were significantly dysregulated. Some of the most robust changes were seen in anterior cingulate (ACC). These findings suggest that in addition to structural abnormalities, lesion studies, and the large body of functional brain imaging studies reporting increased activation in the ACC of depressed patients who respond to a wide range of therapies, there may be a circadian dysregulation in clock gene expression in a subgroup of MDDs. Here, we review human, animal and neuronal cell culture data suggesting that both low-dose ketamine and SD can modulate circadian rhythms. We hypothesize that the rapid antidepressant actions of ketamine and SD may act, in part, to reset abnormal clock genes in MDD to restore and stabilize circadian rhythmicity. Conversely, clinical relapse may reflect a desynchronization of the clock, indicative of a reactivation of abnormal clock gene function. Future work could involve identifying specific small molecules capable of resetting and stabilizing clock genes to evaluate if they can rapidly relieve symptoms and sustain improvement.